Regular Care of a Doctor - Understanding the Vitality of Medical Treatment in a Disability Claim

Welcome to Season 4, Episode 7 of Winning Isn't Easy.  In this episode, we'll dive into the complicated topic of "Regular Care of a Doctor". 

Host Nancy L. Cavey, a seasoned attorney with extensive experience in disability claims, discusses the importance of receiving the regular care of a doctor or medical specialist before, during, and after the course of your disability claim. Disability carriers will capitalize on any inconsistencies in order to deny a claim - one of their most common tactics is to hone in on the medical care a claimant / policyholder is or was receiving for their ailment. Host Nancy L. Cavey discusses how vital it is to make sure you are receiving medical care from a doctor or medical specialist who supports your claim.

In this episode, we'll cover the following topics:

1 - Regular Care of a Doctor

2 - The Consequences of Irregular Medical Care or No Medical Care

3 - Medical Authorization Issues

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://caveylaw.com/get-free-reports/get-disability-book/

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:11]:
 I'm Nancy Cavey, national ERISA disability attorney. Welcome to winning isn't easy before I get started today, I want to give you a legal disclaimer. The Florida bar says, I have to tell you that this podcast is not legal advice, but nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers play, and what you need to know to get the disability benefits you deserve. So off we go with this episode. Over the last several weeks I've been talking about the application process, what you need to know, the work history forms that you are going to be asked to complete, the activities of daily living forms that you have to fill out, and the attending physician statement form that your doctors have got to fill out. Now, I'm going to talk today about three more things you need to know about the disability insurance claims process. And we've talked about and touched on a little bit of this in our last episode. But today it's the medical issues, regular care of doctor issues that I think are important for you to understand.
 
 Speaker A [00:01:19]:
 So I'm going to talk about the requirement that you be under the regular care of a doctor, the consequences of irregular medical care or no medical care, and the role of your physician in your disability claim. Let's take a break before we get started. Look forward to seeing you in a minute.
 
 Speaker B [00:01:37]:
 Have you been robbed of your peace of mind from your disability insurance carrier? You owe it to yourself to get a copy of robbed of your peace of mind, which provides you with everything you need to know about the long term disability claim process. Request your free copy of the book@kvlaw.com today.
 
 Speaker A [00:01:57]:
 Welcome back to winning isn't easy. Let's talk about the policy provision that requires regular care of a doctor. Now the initial claim process can be daunting and confusing, and I believe that you should be getting out that disability insurance policy and reading it cover to cover so you sort of have a sense of the waterfront. But today we're going to concentrate on medical issues. So let's find the policy section that talks about regular care of a doctor. Now normally a provision will read something like to file your disability claim, you have to prove that you're under the care of irregular care of a doctor. So the two crucial elements in this definition are regular care and doctor. And look at the definition of the disability policy for a regular care.
 
 Speaker A [00:02:48]:
 And let me give you an example of what it has been defined as. You personally visit a doctor as frequently as medically required according to generally accepted medical standards. To effectively manage and treat your disabling medical condition, and you are receiving the most appropriate treatment and care which conforms to generally accepted medical standards for your disabling medical condition by a doctor whose specialty or experience is the most appropriate for your disabling condition according to generally accepted medical standards. Now this provision, in my view, brings up a couple of issues. The first issue is, does a telehealth visit count? Well, maybe. Certainly in the age of COVID when doctors offices were closed, you could not personally visit a doctor and you certainly couldn't visit them frequently. The only way that you could consult with a doctor would be by phone or actually by video conferencing. Now, there are some disability carriers who have said that's fine.
 
 Speaker A [00:03:55]:
 There are other carriers I have who've actually denied claims on the basis that the telehealth visit didn't count. It's going to be interesting to see what the federal court does with this because in my appeal letters I'm citing the COVID documentation regarding the specific geographic area my client is in, the positivity rates, whether there were any orders basically for people to shelter, and all the applicable rules and regulations that have been in effect during the period of COVID Now, as we're coming out of COVID I am seeing more demands from disability carriers that there actually be a personal visit. So expect that. And certainly you need to be prepared to deal with that in any way that you think is appropriate. I'm not going to get into the politics of masks or vaccinations or any of that, but you need to do what you need to do to maintain your disability insurance benefits. Now another key here is frequently as medically required to effectively manage and treat your disabling conditions. Many times if you've had an acute injury, you're going to be seeing the doctor a lot in the beginning, but as time progresses and your condition stabilizes, you're not going to see the doctor as frequently. Many times I will reach an agreement with the disability carrier once the claim has been accepted as to how often they want to have my client see the doctor, because there are times when the doctor says, you don't need to come back and see me for a year.
 
 Speaker A [00:05:31]:
 That's probably not going to be well received by the disability carrier, so you may have to see the doctor more than that. But again, we try to hammer out an agreement with the disability carrier as to the frequency. Another issue here is the most appropriate treatment which conforms to generally accepted medical standards. There are some of you who do not trust traditional medicine who use alternative treatment methods. I will be frank with you. Disability carriers do not think that alternative medical treatment is the most appropriate treatment, and they don't think it conforms to generally accepted medical standards. You have the right, certainly, to choose what type of treatment you want, but you need to understand that that can impact your disability claim. And so I like to have my clients who want alternative care to do a mixture of traditional care and alternative care with a sympathetic physician who will condone and approve this alternative care.
 
 Speaker A [00:06:38]:
 Now, the other key words in this definition are a doctor whose specialty or expertise is the most appropriate. If you have Ms Parkinson's, the carrier is not going to be happy if you're treating with your family doctor. That's just the reality. They want to see you treat with a specialist. Same with me. CFS, fibromyalgia and any rheumatological condition. They want you to be treated by a specialist. So you need to understand that going in.
 
 Speaker A [00:07:11]:
 Now, when I started this segment, I said that regular care is defined, but the other factor is the definition of doctor. Doctor can mean a person performing tasks that are within the limits of their medical license, a person with a license to practice medicine and administer drugs, and a person with a doctorate degree in psychology whose primary practice is treating patients, or a person who's legally qualified as a medical practitioner according to the law and regulations of the governing jurisdiction. Now, many disability policies how will not recognize you or your spouse or children or parents or sibling as a doctor for any claim so you can't be treated by a relative. Again, this becomes an issue as to the nature of the medical practice. Is the doctor licensed? Are they practicing medicine within their licensure? I will tell you again that disability carriers are not necessarily wild about long term disability claims where the treatment is by a naturopath or a naturopath, a homeopath, an acupuncturist. Those are not the kinds of claims that have long term success because the disability carrier, quite frankly, doesn't think that that's the right kind of doctor or that they are qualified to provide the treatment. And as I've said, this can be an issue, and it also can be an issue in a psychological claim. I've seen cases where regular care has been defined to be seeing a licensed therapist or psychologist or psychiatrist at least twice a month.
 
 Speaker A [00:08:58]:
 I will tell you that one of the reasons psychological claims get denied is that they criticize the frequency, nature and duration of the treatment, saying that if you were so impaired, you'd be hospitalized. Institutionalized or you'd be lying on the doctor's couch seven days a week. And so regular care can be tricky, depending on the nature of your medical condition. And you won't know whether or not the carrier thinks that your regular care is appropriate until after they deny the claim. So in my view, more frequently after an acute episode and tapering down to a minimum at some point of at least twice a month is appropriate. Now, again, the other issue is going to be what's appropriate care in a psychiatric claim. Disability carriers are notorious for denying a claim on the basis that the care you're receiving is not appropriate because of the lack of the testing that documents the nature of your problems or any improvement. The lack of counseling, including group therapy, the lack of counseling in combination with medications.
 
 Speaker A [00:10:07]:
 They play lots of games with psychiatric claims in terms of the frequency, nature and duration of the care. Now, you also need to understand that two things here, that the disaway carriers are going to have your medical records reviewed by their board certified, in house brownhouse liar for hire doctors who will cherry pick the records. They're going to criticize the lack of documentation in your chart regarding the diagnosis, the treatment plan, your response to the treatment plan, the lack of aggressive measures. So issues regarding medical care can be expected, particularly in psychiatric conditions. And the other thing that you need to understand is that disability carriers have disability duration guidelines. They use a book that's actually written by a psychiatrist who was allegedly consulted with every kind of specialist in the world about every kind of condition in the world, and they've come up with disability duration guidelines and treatment protocols. So the carrier is going to be looking at the accepted criteria, for example, from the American Academy of Orthopedic surgeons for treatment of hip or back issues. But they're going to be looking at these disability determination guidelines as a way to backstop and limit the treat of disability based on the nature of the treatment.
 
 Speaker A [00:11:37]:
 Wow, that's a lot of information. Let's take a break for a moment, and we're going to continue in a minute with the consequences of irregular medical care or no medical care at all. If you are not getting any medical care, you have basically destroyed your claim because the disability carrier requires that you get medical care. So if you're not getting any care, how are you going to prove that you're disabled? In fact, the carrier is going to reason that if you're not getting any medical care, you ought to be able to work regardless of your financial circumstances. Many facilities in your community offer low or no cost medical care it's crucial that you continue to get that medical care, not only to improve your medical condition, but also to assist you in both your long term disability and subsequent disability claims. As I've said before, the care has to be document the extent, nature and level of care that you're getting and confirm that that level of care is consistent with the nature of your diagnosis. And sometimes I have found, particularly when you have physicians who still keep paper charts and you can't read them, that your doctor is going to have to write a detailed letter for which they may charge you, explaining the testing they've performed, the results of the physical examination, the care that they're providing, confirm that the care is appropriate, and comment on your progress. If your doctor is going to play ball with you, it may be time to find a different doctor, one that will support your claim and document your file appropriately.
 
 Speaker A [00:13:38]:
 Now, the disability policy is going to require continued regular and ongoing care. Again, you might want to get out your disability policy and read it and see what it has to say in your particular case. But I assure you, as the sun comes up and the sun sets, the disability carrier is going to continually ask you and your doctor to provide office treatment notes that document not only that you're being seen by a physician on a regular basis, but that the care is appropriate. And I will tell you that this request for information can border on harassment, but we still have to provide this information. So what does a typical policy provision say about regular and appropriate care? Something like this. We may request that you send proof of continuing disability indicating that you're under care of a doctor. This proof has to be provided at your expense and must be received within 45 days of the request by us. So you have to get regular care, it has to be appropriate, and you have to submit this documentation on a regular basis or they will terminate your benefits.
 
 Speaker A [00:14:50]:
 So I'm going to take a quick break here and we're going to come back and we're going to talk about medical authorization issues because this is a question that I get a lot. I'll be back in a second.
 
 Speaker B [00:15:05]:
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 Speaker A [00:15:41]:
 Welcome back to winning isn't easy. Now, we've been talking about policy provisions that require continued regular and ongoing medical care, but it is not uncommon for the policy to provide, and particularly in this section of the policy that you provide the disability insurance company, Dewey, Cheatam and Howe authorization to obtain additional medical information and to provide non medical information as part of your proof of claim. We'll deny your claim or stop sending payments if the appropriate information isn't submitted. Now, let's talk about this and break it down. You are going to have to sign medical releases, but I will try to modify the release to provide that you have to be sent a copy of any letter requesting the medical information, that the authorization is only good for 90 days or 180 days that you actually put on the release the names of the doctors to whom you want the release directed. So I try to control the release of information, but I also send a letter to the doctor saying, we've signed a release that allows you to get the information from the disability insurance or to give to the disability insurance company. But this release doesn't authorize you to have any phone calls with the insurance company or their medical people. And by the way, if you fill out any forms, we want a copy.
 
 Speaker A [00:17:24]:
 And by the way, if the disability carrier sends you a letter asking questions about your case, we want a copy, and we want to see your response before it's sent in. And those are three things that I also try to put in the amended medical release so that there are limits as to what they can get, from whom they can get it, how often they can get it, the nature of their contact with your doctors and the fact that this should be a two way street of disclosure. So if the disability carrier says to you that they can't modify the experience to risk a disability attorney such as myself. Now, this policy provision may also say they want non medical information as part of your proof of claim. Now, what is that? They may want authorization to talk to your employer. They may want authorization to obtain your Social Security file. They may want information about your, and get copies of your income tax returns. So let's talk about these.
 
 Speaker A [00:18:33]:
 I generally do not have a problem with them getting a copy of your personnel file, but I sure as heck have a problem with them having any ex parte conversations with your employer. What does ex parte mean? That means that they're having a conversation that you're not a party of, and that can be a recipe for disaster, because they may ask the employer was this employee, a good employee? Were they having issues? Is this a disgruntled employee? Were they actually requesting time off? Tell me about their job description and what they did. Did you observe them having any problems doing their job? Now this is a third party conversation that you're not a party to, and the information that your employer can give can actually delay your claim, but more often than not results in a denial because we are then stuck ultimately with having to undo the damage that your employer did. Now Social Security files I get this question all the time. The disability carrier is obligated to get a copy of your Social Security disability file. There's a case called Glenn versus metLife. It's a supreme Court case. And the Supreme Court said, hey, you, the disability insurance carrier, have to consider in your decision the decision by the Social Security Administration, and you should be getting a copy of the file and reviewing it.
 
 Speaker A [00:20:02]:
 So if the carrier says, I'm going to ignore it, I'm not going to get it. That's a great grounds for appeal. But if the carrier sends you a letter and says, here's a release, we want to get the file, and you say, heck no, then we've lost that defense and a judge is not going to be particularly impressed with the fact that you impeded the carrier's investigation of your claim. So sign the release. Just ask them to send you a copy of whatever it is they get. Now. Financial documentation. If you have a residual disability claim where you're claiming that you have lost wages and you want to be paid a portion of those lost wages, you're going to have to provide financial documentation.
 
 Speaker A [00:20:47]:
 And yes, I supply it. I even supply it before they ask it. Ask for it. What I don't supply is information that's not relevant, like your spouse's w two or other information that just isn't really relevant. Sometimes disability policies exclude income for rent that you may have from rental income or other income sources. In my view, it's none of their blank business, so I will provide them with redacted parts of the income tax return. There's also, particularly if you're having a residual disability claim, the need to produce financial documents of your monthly profit and loss statements. You may have to produce your billing records or your coded records.
 
 Speaker A [00:21:40]:
 Obviously, you wouldn't want to do that without disclosing patient information or client information, but they're entitled to it. They need that information to calculate benefits, not only to determine what's includable in the calculations, but to do the calculations. So generally I don't have a problem with the financial information. I do try to control that information so you can see that there is a ton of information that you need to submit in conjunction with your disability claim that can be in addition to that and include financial information. If you have any questions about releases please feel free to contact my office and we can give you some advice about that. Well, that's it for today's episode. I hope you enjoyed this episode and in next week's episode we are going to be talking about the role of your physician in your disability claim. Your doctor can make or break your disability claim and we're going to spend the entire episode about talking about their role, the attending physician statement forms and what information the Doctor has got to supply.
 
 Speaker A [00:22:57]:
 So I look forward to talking with you in our next podcast episode. If you like this episode, please share it, send us a shout out and please stay tuned to next week's episode. Thanks.